Download My Health Action Plan My Health Issues / Long Term Conditions

My Health Action Plan
My Health Issues / Long Term
Conditions
Place to record:
 What it is
 How it affects me
 Support needs
My Immunisations
Place to record:
 Immunisations and date
received/due.
My Family Health History
People I see about my Health.
My Medication
Medical Appointment Form
Health Condition Management Plan
Planning Form
Place to record:
 Family illnesses/conditions
Place to record:
 Who I see
 When I see them
 Why I see them
 Next appointment due
Place to record:
 What I take
 Why I take it
 Side effects
 Date for review
Place to record
 Outcome of medical appointments
Place to record
 The nature of the condition
 How it affects the person
 Associated risks
 Strategies/practices to manage it.
Place to record:
 Issues identified
 Tasks to do
 By who and when
 Date for review
AppA_1.6_BestPossibleHealth_MyHealthActionPlan
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MY HEALTH ACTION PLAN
My Health Issues/Long Term Conditions are:
Name: _________________________
How I communicate: ____________________________________________
Date of Birth: ___________________
Completed by: _________________________
What is it?
e.g. Bowel Difficulties, Ulcer, Allergy, Gastric
Problems, Epilepsy, Diabetes, Asthma.
1.
2.
3.
4.
5.
6.
7.
How does this affect me?
Date: ________________
My Support Needs
My Health Action Plan – My Immunisations
Have you had a flu jab?
Yes
No
List any Immunisations you have had
Date Received
Is this required/date due
Comment
Any required/date due
Comment
My Health Action Plan – My Family Health History
IF the person’s parents, grandparents, brother or sister have had any of these illnesses or health conditions
please tick the box.
Asthma
Heart disease
Cancer
High blood pressure
Low blood pressure
Diabetes
Eczema
Thyroid
Epilepsy
Mental health
Allergies
Stroke
Sickle Cell Anaemia
Glaucoma
Other - say below
Please say more about your family history here:
My Health Action Plan – People I see about My Health
Who I see
When I see them
Why I see them
Next appointment
Signed:
My Health Action Plan - My Medication
Medication
What is it for?
Side Effects
Date for Review
MY HEALTH ACTION PLAN - MEDICAL APPOINTMENT FORM (MAF)
CRITERIA FOR USE:
RECORDING OUTCOMES OF MEDICAL
APPOINTMENTS
PERSON’S NAME: ______________________________ DATE OF BIRTH: ___________
ADDRESS: ________________________________________________________________
___________________________________________________________________________
REASON FOR APPOINTMENT: _______________________________________________
___________________________________________________________________________
___________________________________________________________________________
SEEN BY: __________________________________________________________________
ACCOMPANIED BY: _______________________________ DATE: _________________
OUTCOMES: ______________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
NEXT REVIEW DATE: _______________ SIGNED: ________________________________
My Health Action Plan – My Health Condition Management Plan
When the person has a diagnosed health condition such as Epilepsy, Diabetes, Asthma, Constipation, Eczema or an Allergy,
for example, a Health Condition Management Plan for that condition must be completed. This becomes the one document
people rely upon to tell them how to successfully support the person with their health condition.
The Health Condition Management Plan must clearly describe the nature of the condition, how it affects the person, the risks
associated with the condition and the strategies/practices that will be used to manage it. Depending on the health condition
being managed, a medical practitioner may also need to complete part of the plan: for example, the medical practitioner’s
instruction and authorisation to administer Stesolid/Midazolam is written into the person’s Epilepsy Management Plan.
Staff should consult with relevant medical personnel e.g. Epilepsy Nurse Specialist, Neurology Support Team, Diabetic
Nurse Specialist, to source information relating to the particular health issue and how to best support the person’s condition.
Please refer to Intranet – Health – Health Resources which is a source of information for a number of the more commonly
occurring health conditions.
If the person has a particular health condition that requires some specific knowledge, skill or training then this needs to be
discussed with one’s line manager in the first instance who will then refer the matter to the Evaluation and Training
Department.
My Health Action Plan – Planning Form
Health Issues Identified
Things to Do
By and When
(Person to do things
identified and timescale)
Date of Reviewing Health Plan:
______________________________________________
Reviewed by:
______________________________________________
______________________________________________
Review Date